Many Grade A hospitals have been punished for medical insurance violations: Industry reflections on stricter supervision
Recently, the National Health Insurance Administration has released a number of penalties for medical insurance violations in medical institutions, involving many Grade A hospitals across the country. This incident has aroused widespread attention from the society and also reflects the trend of stricter supervision of medical insurance funds. The following are the focus content and structured data analysis that has been hotly discussed across the Internet in the past 10 days.
1. Event background and punishment overview
According to the notice from the Medical Insurance Bureau, a total of 12,000 cases of illegal use of medical insurance funds were investigated and dealt with in the third quarter of 2023, and 2.13 billion yuan of funds were recovered. Among them, Grade A hospitals account for 17%, and violations are mainly concentrated in the following aspects:
| Violation Type | Number of hospitals involved | Typical performance |
|---|---|---|
| Overdiagnosis and treatment | 38 companies | No indication examination, decomposition of hospitalization |
| False charges | 25 companies | False record surgery items, high fees |
| Switch projects | 19 companies | Reimbursement of medicine and equipment replacement |
2. Analysis of key punishment cases
1.A Grade A Hospital in Beijing: 12.8 million yuan of medical insurance fund was recovered for violations such as "intraoperative price increase" and was punished with a double penalty;
2.A specialized hospital in Shanghai: Fictional records of 44 cataract surgery cases and cancelled the designated medical insurance for one year;
3.A comprehensive hospital in Guangzhou: The president was given a warning and talked with a warning through illegally obtaining funds through "hung bed hospitalization".
| area | Penalty amount | Rectification requirements |
|---|---|---|
| North China | 65.3 million yuan | Establish an intelligent audit system |
| East China | 48.2 million yuan | Improve the internal audit system |
| South China | 31.7 million yuan | Carry out full-staff training |
3. Public opinion reaction and industry influence
1.Patient voice: More than 72% of respondents support strengthening supervision, but are worried about "accidentally injuring" normal medical needs;
2.Hospital response: Many institutions have stated that they will promote the DRG payment reform, and a provincial hospital has launched an anti-fraud system;
3.Expert opinion: The China Medical Insurance Research Association pointed out that it is necessary to balance the regulatory efforts and medical innovation space.
4. Deep Pivot
| year | Number of cases investigated and dealt with | Recover funds (billion yuan) | Grade A hospitals account for |
|---|---|---|---|
| 2021 | 54,000 | 43.5 | 12% |
| 2022 | 78,000 | 68.2 | 15% |
| 2023 (first three seasons) | 91,000 | 89.7 | 18% |
5. Future regulatory trend forecast
1.Technology empowerment: Full coverage of the national medical insurance intelligent monitoring subsystem will be achieved by 2024;
2.Standard refinement: The matching requirements for clinical diagnosis and treatment guidelines and medical insurance catalogue have been increased to more than 95%;
3.Joint punishment: It is planned to establish a "blacklist" system and link it with the assessment of the Health Commission.
This incident reflects that the supervision of medical insurance fund has entered the "zero tolerance" stage. How to maintain medical quality while ensuring the safety of the fund will become a transformation issue that medical institutions must face. It is worth noting that data during the same period showed that the use efficiency of hospital medical insurance funds that are standardized to operate increased by 6.8% year-on-year, indicating that compliance and efficiency are not contradictory.
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